CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2012 ending 12/31/2012 Date of Report:02/16/2013 Page: 1
List order: No List
Payclass Filters:MED
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 7192 20777.50000 768138.2500 36.9697
Subtotal (Total Children Is Unduplicated) 7192 20777.50000 768138.2500 36.9697
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.000000 13.0500 13.0500
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 34 34.000000 309.7400 9.1100
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 14 14.000000 130.7600 9.3400
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 35 35.000000 760.5500 21.7300
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.000000 48.9400 24.4700
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 63 104.500000 7837.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 36 56.500000 4237.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 15 24.500000 1837.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 26 48.500000 3637.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 91 152.000000 8436.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 641 987.500000 74062.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 341 565.500000 42412.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 267 376.500000 28237.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1124 1734.000000 96237.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 347 500.500000 37537.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 140 140.000000 7088.2000 50.6300
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 18 18.000000 586.0800 32.5600
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 6 7.000000 339.5000 48.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 37 37.000000 1794.5000 48.5000
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 6 6.000000 291.0000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 27 27.000000 1309.5000 48.5000
SCREEN-T1023-SCREENING 1 1.000000 50.0000 50.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 47 48.000000 2328.0000 48.5000
Subtotal (Total Children Is Unduplicated) 1687 4920.000000 319522.8200 64.9437
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 7 11.000000 275.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2877 21134.00000 1056650.0000 49.9976
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 9 12.000000 600.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 319 1818.914200 123349.1100 67.8147
OCCT-97530HM-OT SESSION BY OT ASST 16 62.500000 3395.0000 54.3200
PHY-97110-PT SESSION BY LICENSED PT 471 2344.385600 159136.9000 67.8800
PHY-97110HM-PT SESSION BY PT ASST 33 148.500000 8066.5200 54.3200
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 5 6.000000 300.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 498 2666.000000 180858.7200 67.8390
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 3 6.500000 353.0800 54.3200
SPL-92508-GROUP SPL SESSION PER CHILD 3 5.250000 69.3000 13.2000
Subtotal (Total Children Is Unduplicated) 3664 28215.04980 1533053.6300 54.3346
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Total 53912.549800 2620714.7000 48.6105
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Number of Children (Unduplicated) With at Least One Service 7920
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Center 02
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 787 551.000000 20063.2500 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
377 438.000000 24393.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1164 989.000000 44457.0000 0.0000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 12 7.500000 277.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 390 313.750000 14148.0000 0.0000
P 2160 1297.750000 53983.5000 54019.5000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
3 4.500000 337.5000 0.0000
Other 81 81.000000 1185.3400 0.0000
---------------------------------------------------------
Total 2646 1704.500000 69931.8400 54019.5000
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 25 34.500000 1276.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 999 1219.500000 47168.5000 0.0000
P 2501 2882.500000 109750.2600 109477.1200
D 1 0.500000 18.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 2132 7136.000000 360621.6400 360217.6600
T 0 0.000000 0.0000 0.0000
714 947.750000 52099.6700 0.0000
Other 6 9.750000 497.2700 321.5200
---------------------------------------------------------
Total 6378 12230.500000 571432.3400 470016.3000
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 2.500000 92.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 5859 5979.000000 265543.2600 0.0000
P 3 3.250000 120.2500 120.2500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1782 5248.000000 291618.6200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7646 11232.750000 557374.6300 120.2500
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 230 131.000000 4847.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 8376 6128.750000 262764.7500 0.0000
P 13 22.000000 1496.6300 1428.7500
D 0 0.000000 0.0000 0.0000
S 1 0.250000 9.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2104 5944.750000 328321.0300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 10724 12226.750000 597438.6600 1428.7500
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2 2.250000 159.2500 0.0000
P 1162 1087.000000 45334.2500 45334.2500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
700 719.500000 38755.3500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1864 1808.750000 84248.8500 45334.2500
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 196 209.250000 11584.4100 0.0000
P 1393 945.000000 37526.7500 37526.7500
D 1 0.500000 18.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1225 1200.549800 65555.2000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2815 2355.299800 114684.8600 37526.7500
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 59 66.750000 2526.7500 0.0000
P 1939 1877.000000 73350.2500 73350.2500
D 0 0.000000 0.0000 0.0000
S 4 3.500000 129.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2183 2026.500000 128146.9900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4185 3973.750000 204153.4900 73350.2500
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 1.000000 37.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1152 1090.250000 45684.7500 0.0000
P 872 971.250000 44277.7500 44277.7500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 5 7.750000 495.7500 0.0000
T 3 9.000000 450.0000 450.0000
1556 5312.000000 286047.7800 285482.9800
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3590 7391.250000 376993.0300 330210.7300